NECESSITY,
FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the
Cabinet for Health Services and placed the Department for Medicaid Services and
the Medicaid Program under the Cabinet for Health and Family Services. The
Cabinet for Health and Family Services has responsibility to administer the
Medicaid Program. KRS 205.520 authorizes the cabinet, by administrative regulation,
to comply with any requirement that may be imposed or opportunity presented by
federal law for the provision of Medicaid to Kentucky's indigent citizenry.
This administrative regulation establishes the provisions relating to the early
and periodic screening, diagnosis and treatment service and early and periodic
screening, diagnosis and treatment special services for which payment shall be
made by the Medicaid Program on behalf of both categorically needy and
medically needy children under age twenty-one (21).

Section 1.
Definition. (1) "By report" means a service or item for which a
maximum allowance has not been established because the item is rarely billed to
the Kentucky Medicaid Program or because the service is unusual, variable, or
new.

(2)
"Department" means the Department for Medicaid Services or its
designated agency.

(3)
"EPSDT" means early and periodic screening, diagnosis, and treatment.

(4)
"Periodicity" means the frequency with which an individual may be
screened or rescreened.

(5)
"Recipient" means a Medicaid eligible child under the age of
twenty-one (21), including the month in which the child becomes twenty-one
(21).

(6)
"Screening" means the review of the health and health-related
conditions of a recipient by a health care professional to determine if further
diagnosis or treatment is needed.

Section 2.
Screening Provider Participation Requirements. A health care provider meeting
the requirements established in this section shall be eligible to participate
in the Medicaid Program as a screening provider:

(1) A physician
shall be licensed in the state of Kentucky;

(2) An early and
periodic screening clinic or other organization qualified to provide a
screening service, including a local health department, shall be under the
direction of a licensed physician, pediatric advanced registered nurse
practitioner, or registered professional nurse currently licensed by the state
of Kentucky who shall be responsible for assuring that the requirements of participation
are met and that the procedure established by the Medicaid Program are carried
out;

(3) A screening
clinic conducted under the direction of a registered professional nurse or an
advanced registered nurse practitioner shall have a licensed physician acting
as medical consultant; and

(4) A screening
examination or test performed by licensed professional staff, or supportive
staff under the direct supervision of the licensed professional, shall be in
accordance with the professional practice standards for the profession.

Section 3.
Screening. An EPSDT screening service shall be directed toward the early
detection of a disease or abnormality. The service shall be appropriate for the
age and health history of the recipient and shall include, as applicable:

(1) An initial,
periodic, or additional health assessment of a recipient provided in accordance
with Sections 2 and 5 of this administrative regulation which includes the
following:

(a) Health and
development history;

(b) Unclothed
physical examination;

(c) Development
assessment and mental health screening;

(d) Assessment and
provision of immunizations as appropriate for age and health history;

(e) Assessment of
nutritional status;

(f) Vision
testing;

(g) Hearing
testing;

(h) Laboratory procedures
appropriate for age and population groups, including lead screening and testing
as appropriate;

(i) Director
referral for a dental service for diagnosis and treatment for a child two (2)
years of age and over; or

(j) Anticipatory
guidance and health education;

(2) A health
assessment examination, or evaluation of a recipient by a licensed or certified
health care professional acting within his scope of practice, at intervals
other than those specified in Section 5 of this administrative regulation
indicated by medical necessity, to determine the existence of a defect,
physical or mental illness, or condition; or

(3) Any other
recipient encounter with a licensed or certified health care professional that
results in the determination of the existence of a suspected:

(a) Defect;

(b) Illness;

(c) Medical
condition; or

(d) A change or
complication in a medical condition.

Section 4.
Immunizations. Each screening provider participating in accordance with Section
2(1), (2), and (3) of this administrative regulation shall be required to make
available, at the time of screening, immunizations appropriate for age and
health history of the recipient being screened.

Section 5.
Periodicity Schedule. The periodicity schedule, which is established in the manual
incorporated by reference in this administrative regulation, shall define the
age appropriate services and time frames for screenings. The periodicity
schedule shall be recommended by the Department for Public Health and approved
by the Department for Medicaid Services. An additional medical or dental
assessment shall be provided if medically indicated. The periodicity schedule
is incorporated by reference in the "Early and Periodic Screening,
Diagnosis, and Treatment Services Manual".

Section 6. Diagnosis
and Treatment. If referral for additional service is indicated, further
diagnosis and medical treatment services shall be covered if the service or
diagnosis:

(1) Is otherwise
covered by the Medicaid Program; or

(2)(a) Is not
otherwise covered by the Medicaid Program; and

(b) Meets the
requirements for EPSDT special services as provided for in Section 7 of this
administrative regulation.

Section 7. EPSDT
Special Services. EPSDT special services shall include other health care,
diagnostic services, preventive services, rehabilitative services, treatment,
or other measures described in 42 U.S.C. 1396d(a), that are not otherwise
covered under the Kentucky Medicaid Program and that are medically necessary,
as defined in Section 9 of this administrative regulation, to correct or
ameliorate a defect, physical or mental illness, or condition of a recipient.

Section 8. EPSDT
Diagnostic and Treatment Provider and EPSDT Special Services Provider
Participation Requirements. (1) An EPSDT diagnostic or treatment provider shall
meet the requirements for participation in the Kentucky Medicaid Program as
specified in Title 907 KAR for the particular diagnostic or treatment service
rendered.

(2) Except as
otherwise specified in Title 907 KAR, a provider seeking to provide an EPSDT
special service, as established in Section 7 of this administrative regulation,
shall first contact the department in writing or by telephone to apply for
enrollment to become an EPSDT special services provider. In order to be enrolled,
the provider shall supply documentation or other evidence which establishes
that all of the following conditions are met:

(a) The provider
shall:

1. Be licensed,
certified, or authorized state law to provide the service; and

2. Not be
suspended or otherwise disqualified.

(b) If the
provider is out of state, the provider shall meet comparable requirements in
the state in which he does business.

Section 9. Prior
Authorization for EPSDT Diagnosis and Treatment Services and EPSDT Special
Services. Except as otherwise provided for in this section or in 907 KAR
Chapter 1 or 3, an EPSDT diagnosis or treatment service or an EPSDT special
service which is not otherwise covered by the Kentucky Medicaid Program shall
be covered subject to prior authorization if the requirements of subsections
(1) and (2) of this section are met. The department shall review a request for
a service to determine medical necessity without regard to whether the screen
was performed by a Kentucky Medicaid provider or a non-Medicaid provider.

(1) A request for
prior authorization for an EPSDT service established in Section 6(1) or (2) of
this administrative regulation shall state that the request is for an EPSDT
service, and shall be accompanied by the following information:

(a) The primary
diagnosis and significant associated diagnoses;

(b) Prognosis;

(c) Date of onset
of the illness or condition, and etiology if known;

(d) Clinical
significance or functional impairment caused by the illness or condition;

(e) Specific types
of services to be rendered by each discipline with physician's prescription if
applicable;

(f) Therapeutic
goals to be achieved by each discipline and anticipated time for achievement of
goals if applicable;

(g) The extent to
which health care services have been previously provided to address the defect,
illness, or condition, and results demonstrated by prior care if applicable;
and

(h) Other
documentation necessary to justify the medical necessity of the requested
service.

(2) Except as otherwise
provided for in 907 KAR Chapter 1 or 3, a request for approval of a service
shall meet the standard of medical necessity for EPSDT if the following
applicable criteria are met:

(a) The service
shall be to correct or ameliorate a defect, physical or mental illness, or
condition;

(b) The service to
be provided shall be medical or remedial in nature;

(c) The service
shall be individualized and consistent with the recipient's medical needs;

(d) The service
shall not be requested primarily for the convenience of the beneficiary,
family, physician or another provider of services;

(e) The service
shall not be unsafe or experimental;

(f) If an
alternative medically accepted mode of treatment exists, the service shall be
the most cost-effective and appropriate service for the child;

(g) A request for
a diagnosis or treatment service in a community-based setting:

1. May not be
approved if the costs would exceed those of equivalent services at the
appropriate institutional level of care; and

2. Shall be
individually assessed for appropriateness in keeping with the standards of
medical necessity and the best interest of the child.

(h) The service to
be provided shall be:

1. Generally
recognized by the appropriate medical profession as an accepted modality of
medical practice or treatment;

2. Within the
authorized scope of practice of the provider; and

3. An appropriate
mode of treatment for the medical condition of the recipient;

1. Well designed
and well conducted investigations published in peer-review journals,
demonstrating that the service is intended to produce measurable physiological
outcomes;

2. In the case of
psychological or psychiatric services, measurable psychological outcomes, concerning
the short and long-term effects of the proposed service on health outcomes;

3. Opinions and
evaluations published by national medical organizations, consensus panels and
other technology evaluation bodies supporting provision of the benefit, shall also
be considered if available;

(j) The predicted
beneficial outcome of the service shall outweigh potential harmful effects;

(k) The services
improve the overall health outcomes as much as, or more than, established
alternatives.

(3) If
reimbursement is being sought on a "by report" basis, a description
of the service, the proposed unit of service, and the requested dollar amount
shall be included with the request for authorization.

(4) A prior
authorization request for an EPSDT service shall be reviewed for medical
necessity without regard to the source of the referral to the service.

(5) A school-based
health service provided in accordance with 907 KAR 1:715 which is included in
an authorized Individual Education Program (IEP) shall be considered to be
medically necessary and shall not be subject to further Medicaid prior
authorization requirements.

Section 10. Appeal
Rights. A recipient shall have the right of appeal as established in 907 KAR
1:563.

Section 11.
Incorporation by Reference. (1) "Early and Periodic Screening, Diagnosis,
and Treatment Screening Services and Early and Periodic Screening, Diagnosis,
and Treatment Special Services Manual", Department for Medicaid Services,
May 1998 Edition, is incorporated by reference.